Provider Demographics
NPI:1184960494
Name:FERNANDEZ, NIDIA (DOM)
Entity type:Individual
Prefix:DR
First Name:NIDIA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:DR
Other - First Name:NIDIA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOM, OMD, AP
Mailing Address - Street 1:449 CENTRAL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3863
Mailing Address - Country:US
Mailing Address - Phone:813-760-0055
Mailing Address - Fax:
Practice Address - Street 1:449 CENTRAL AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3863
Practice Address - Country:US
Practice Address - Phone:813-760-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2527171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC00NG.OtherFLORIDA BLUE